military history
The Heritage of Naval Surgery
Lieutenant Commander (Professor) Noel Tait RANR
Introduction
LCDR Tait is a general surgeon with interests in
upper gastrointestinal cancer surgery. He has been
a consultant surgeon to the ADF since 1985.Prior to
his current appointment in 2008 he was Associate
Professor of Surgery at the Australian National
University Medical School (ANU) and Sub-Dean of the
ANU Clinical School at Calvary Hospital in Canberra. In
2008 he was awarded a Rotary International Fellowship
in recognition of community services in medicine and cancer care.LCDR
Tait currently acts as Reserve Coordinating Officer Fleet Health.
Correspondence: ntait@uow.edu.au
Surgeons in the modern Royal Australian Navy (RAN) share a
rich history and heritage handed down to us, particularly from
surgeons of the Royal Navy during the age of sail from the 16th
to the late 19th century.to1900. Naval surgery became a separate
branch of military surgery. It became standard practice to
include surgeons as a standard part of a ship’s scheme of
complement. Areas of each ship were allocated for surgeons
to operate using surgical instruments and supplies and assisted
by medical sailors. The discipline of naval surgery evolved
to include specific training for surgeons in the treatment of
common illnesses encountered at sea - this being previously
the responsibility of ships’ captains. The first hospital ship,
Therapetia, a trireme, accompanied the Athenian fleet in the
5th century BCE (1). Much later, in 1608, the Royal Navy (RN)
provided its first hospital ship Goodwill for an expedition to
Algeria (2). During the Crimean War 100,000 wounded British
soldiers were repatriated by Royal Navy Hospital ships(3).
Surgeons of the Royal Navy became indispensable members
of fighting ships, facilitating the return to duty of wounded
sailors and boosting shipboard morale by their caring
humanitarian approach.
This paper follows the landmarks which produced this unique
heritage. Four periods of naval or military surgery will be
described: 1) ancient Egyptian surgery between 1700 and 3000
BCE; 2) 16th century developments in wound care; 3) the 19th
century care of convicts during their transportation to Australia
from England; and 4) examples of executive skill, courage and
innovation displayed by 20th century naval surgeons in war and
in support of peace-time civilian crises.
The History of Military Trauma Surgery
The frozen remains of a Neolithic hunter were found by two
walkers in the Otztal mountains on the border between Austria
and Italy in September 1991. This discovery revealed the
earliest evidence of rudimentary wound care occurring at least
3,300 years BCE. ‘Otzi the Ice Man’, as he came to be known,
died of a massive haemothorax 5,300 years ago following
penetrating chest trauma: an arrow had pierced his left thorax
and lacerated his left subclavian artery.( 5,6,) The remains of
primitive wound dressings applied to Otzi demonstrate that
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even in prehistoric times conflicts inevitably required medical
support. Only 300 years later, in 3000 BCE Egyptian court
physicians began to record their surgical treatments – mostly
of the ruling class. The earliest naval surgery developed pari
passu with the trauma incurred in the earliest naval warfare (1)
The Edwin Smith Papyri-a textbook of ancient
Egyptian surgery
Edwin Smith was a British archaeologist who discovered
ancient medical tracts, written in ancient Egyptian Hieratic
script around 1700 BCE. They represent our oldest known
surgical treatise. The case descriptions and treatment
recommendations recorded in them were based on clinical
experiences accumulated by earlier court physicians up to
1,000 years prior; that is from approximately 3,000 years BCE.
(7, 8)
The ancient surgeons responsible for compiling these cases
used what clinical information was available to them to
diagnose, determine prognoses and advise on treatments, much
as contemporary clinicians do today. However, unlike current
practice, there was no diagnostic support. The competence of
ancient surgeons depended on their use of innate intelligence,
knowledge and clinical acumen. What few surgical instruments
they possessed needed to be applied with skill and courage.
The Edwin Smith papyri systematically describe injuries
starting at the head and proceeding downwards through body
regions like a modern anatomy textbook. The treatments are
remarkably rational and there is little recourse to magic. The
cases discussed in the Papyri are classified into three clinical
prognoses: favourable, uncertain and unfavourable, much as
modern triage does.
An unfavourable clinical verdict was delivered in ancient
Egyptian words meaning ‘an ailment not to be treated’.
Nevertheless such patients still received humane care scientific
interest and the best possible attempts to alleviate suffering
in under-resourced and austere circumstances, often in war.
One example of an unfavourable outcome was chest injury
with pneumothorax. Surgeons of the time understood that
attempts at treatment were futile and inhumane. Far more
treatable trauma patients occurred on the battlefield and these
received higher priority.
Due to the tenacity, skill and innovation of subsequent generations
of military surgeons chest injuries with pneumothorax are now
effectively and safely treated by surgeons.
Ambroise Paré.
Surgery has advanced over the centuries because of the
humanity and skill of military surgeons working under the
most inhumane and austere conditions; the conditions typical
of surgery during war or civilian crisis. Ambroise Paré (1510 –
1590) was such a surgeon who spent much of his surgical life
working under these conditions. He advanced the surgical care
of war wounds by replacing hot iron cautery for the control of
bleeding using ligatures instead.
Physicians of Paré’s time mistakenly attributed the terrible
septic outcomes from war wounds and operations to the
effects of a poison in gunpowder. Reasoning that this could
be neutralised by heat, they prescribed cautery of wounds with
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boiling elder oil. The standard of care was to pour boiling
oil over open amputation wounds after surgery. To heal the
stump, the edges were left open to heal slowly by secondary
intention. This was intended to improve the survivability of
the soldier (or sailor) from the injury. However the extra
trauma induced by cautery caused horrible pain and further
diminished the already compromised physiologic reserves of
the unfortunate victim.
During the Siege of Turin in 1537 Paré’s supply of elder oil
ran out. Driven by his desire to provide optimum treatment
to those under his care he confiscated supplies from the
palace kitchen and concocted a substitute made of egg
yolks, oil of roses, and turpentine. This was applied cold to
the amputation wound because there was no fuel. When he
anxiously reviewed his soldier patients the next morning
Paré found the conventionally treated patients in pain and
unwell and mostly delirious while those not cauterised were
comfortable, clear headed and relatively free of pain. (9, 10)
Paré proved that relief of pain was important and overturned
conventional wisdom using his own powers of observation and
innovation. He described his findings clearly, recognising their
significance and arguing that his innovative practise produced
better patient care. Paré’s new treatments were finally accepted
by the majority of his contemporaries.
Surgery in the British Navy
Naval surgeons participated in the growth of naval power
which proved crucial to the development of the British Empire.
The practice of naval surgery had its origins in the era of the
Tudor navy of King Henry VIII when gunpowder and cannon
were introduced. Sea travel and sea warfare, already cursed by
diseases related to the cramped conditions on sailing ships,
poor nutrition at sea and exposure to diseases in foreign lands,
now produced horrendous wounds resulting from explosions
and missiles. While fire had always been a threat to sailing
ships, the advent of explosive munitions brought searing blasts,
sudden fierce fires and overwhelming exposure to noxious
gases not previously experienced. Prior to the advent of
firearms, naval battles consisted of ramming, fire ships, archery
and close quarter combat between crews whose ships would
be deliberately entangled to facilitate boarding and counter
boarding. Fighting was hand-to-hand, between sailors armed
with weapons that bludgeoned, stabbed and slashed one victim
at a time. If they impeded the ability of the combatants to get
at each other, the dead and injured were thrown overboard.
Naval battles under sail in the era of explosives were often
carried on at very close quarters with ships locked together,
cannons and muskets blasting away at point blank range.
The pattern, the number and the rate of accrual of injuries
escalated rapidly. (11) Surgeons in such battles described large
numbers of severely injured men that quickly swamped the
limited space and resources that could be allocated to their
care in a sailing warship
Naval surgeons in convict ships to the Australian
colonies.
The vessels engaged in transporting convicts to the Australian
penal colonies were overcrowded, poorly equipped merchant
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ships. Though comprised of chartered merchant vessels, the
First Fleet was sponsored by the British government with the
commissioners of the Royal Navy responsible for supervising
the vessels’ refits and victualling in preparation for the voyage
to Port Jackson. Few of those responsible understood the
magnitude of the journey. A naval surgeon was posted to each
ship. (12) These were men steeped in the traditions of the
navy and most importantly they understood the ethics of naval
service. These naval surgeons had to care for crews, convicts,
fee-paying passengers and marine detachments alike. They
also resisted the unbridled cruelty and inhumanity of masters
who had learnt the craft of transporting humans as cargo in
the slave trade, mainly between Africa and America. Ships’
surgeons also exposed the callous greed of the ship owners
who repeatedly sent unseaworthy, under-victualled ships on the
long voyage to Australia without any concern for the health or
safety of the convicts and crews.
These naval surgeons had acquired vast experience in treating
injuries during war and in managing the health of crews on
protracted voyages and in foreign climates. They were uniquely
qualified for the roles that befell them during the era of convict
transportation.
The surgeons of the First Fleet lost few convicts to disease or
trauma. Transported convicts had spent months in fetid prison
hulks while awaiting transportation to Australia. Some of those
transported on the first fleet were fitter on arrival at Botany
Bay than when they left England. Sadly, subsequent fleets did
not fare so well, principally because the naval surgeons were
removed from them. Responsibility for fit-out, victualling and
allocation of ship surgeons in subsequent fleets sent to Sydney
Cove became the responsibility of private contractors. Though
these contractors were required to work to Navy standards,
abuses were common. Consequently death rates on the voyages
rose disastrously once the contractors were free to appoint and
to control their own surgeons.
The Second Fleet, which was managed purely by private
contract, was a disaster. Almost 300 of 1000 convicts transported
died during the journey from disease, sadistic floggings, general
neglect, and the withholding of rations and clothing. Those who
survived were sold at inflated prices in markets at Sydney Cove.
Another 150 died after landing. Much to the disappointment
of Governor Arthur Phillip, the majority of survivors of this fleet
were so ill and weakened that they were unable to contribute
to the food production and economy of the already starving
colony – they simply added to the colony’s burden. In response
the Navy commissioners reassumed responsibility for medical
care on convict transport ships and placed a naval surgeon
on each vessel. They reported to the Navy, rather than to ship
owners and their merchant seaman captains. Inevitably conflicts
arose between naval surgeons and masters of convict ships.
(13) The re-introduction of naval surgeons into the British
convict ship system saw the transportee death rate plummet.
The embarked naval surgeons were given the special title of
Surgeon Superintendent to enhance their status beyond their
stated rank. This made it possible (but not easy) for them to
balance the commercial interests of ship owners and merchant
captains, and the interests of the British Government and naval
commissioners. The role of a naval Surgeon Superintendent on
a convict transport ship required firmness along with tact and
diplomacy to moderate the cruelty and avarice that confronted
them at sea. They did this while exercising clinical skill and
experience, tempered by naval discipline, to deliver medical care
at sea and to meet the expectations of the naval commissioners at
home and Governor Arthur Phillip. The first four ships to make
the trip to Botany Bay with naval surgeons again supervising
the care of convicts and crew managed to deliver almost 700
convicts, as well as marine detachments and other passengers,
with only fourteen deaths incurred and most of the landed
convicts fit for work to support the colony. This was a remarkable
outcome given the convicts were often in parlous health after
being held for long periods in rotting, unsanitary prison hulks
before being transferred to the care and protective supervision
of naval surgeons in the convict transport ships.
One of these Surgeon Superintendents was Thomas Reid. An
Irish born graduate of the Royal College of Surgeons, Reid
made two voyages on convict ships to the New South Wales
colony at Sydney Cove in 1817 and to Van Diemen’s Land in
1820. At that time Royal Navy surgeons were still obliged to
allocate part of their small salary to the purchase of a navyapproved kit of surgical instruments before boarding ship.
This practice was unlike the army, whose surgeons had their
instruments provided for them by the officers and men of the
regiment to which they were assigned.(14) Only from 1805 had
the Royal Navy finally taken over the expense of providing ship’s
medicines, previously also a responsibility of the surgeon, to be
met out of his salary. Reid, using courage, common sense and
his Navy- approved instruments was so successful in getting his
convict and marine detachment charges to Australia in good
health that Elizabeth Fry, a renowned agitator for prison reform
at the time, cited him as a model for government policy on the
care of convicts at sea and a role model for other surgeons.
Unfortunately for later transportees war broke out between
Britain and France under Napoleon. The Royal Navy, now
desperately short of surgeons for its warships could no longer
release them for the Botany Bay convict ships. The death rate
on convict transport ships soared again. Fortunately there was
help waiting at the colony. William Redfern (1774-1833) had
trained as a naval surgeon but became embroiled in the mutiny
by British sailors at Nore. Though his role was confined to urging
the sailors to “be more united amongst yourselves” Redfern
was sentenced to hang but his sentence was later commuted
to transportation to the Australian penal colony at Sydney
Cove. There was a desperate shortage of trained doctors in the
colony so Redfern was soon busy doing what he was trained for,
attending to the sick whether free colonist, emancipist or convict.
Even though he was a convict on a ticket of leave, Redfern was
unrelenting in his advocacy for all aspects of health care in the
colony: lobbying against excessive punishments (especially the
lash), urging improvements in diet and sanitation, agitating
for better housing for convicts. Though as a rash young man
Redfern had plunged from proud naval surgeon to convicted
and transported felon he never lost sight of, or ceased to live by,
his naval surgery heritage. He deserved the honour of having the
Sydney suburb of Redfern named after him. (15, 16)
The role of a Navy surgeon
Naval surgeons are, as are all members of a warship’s
complement, responsible to the vessel’s commander. However,
the special role served by surgeons as carers for all members
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of a crew, as intellectual companions for ship captains and
as sea-going scientists, has permitted special relationships
between surgeons and their commanders. The special roles
and relationships moulded around surgeons at sea brought
unique responsibilities but permitted freedoms that could
be enjoyed by the average member of a war ship’s crew. This
remains the case today.
The twentieth century, though an era of revolutionary technical
advances in ship design, sea keeping qualities and war fighting
abilities, still required courage and innovation in the provision
of surgical care at sea, on the surface and below, at peace and
at war. During WWII the USN Surgeon General, VADM Ross
T.McIntyre was responsible for an enormous expansion in Navy
health care capacity. This was in preparation for the expected
massive casualties from naval warfare and amphibious landings
needed to reverse the advances made by the Japanese. He
leased hotels and converted them to hospitals, took over army
hospitals at General Patton’s tank training facilities, lobbied for
funds and facilities to improve medical care on war ships and
to commission hospital ships and fast-tracked the entry and
training of USN surgeons and medical corpsmen. McIntyre’s
strategic vision, organisational courage and executive skill
were crucial to the campaign. McIntyre did not tire after the
Pacific conflict ended, spending the rest of his working life
caring for and representing those left handicapped by war
wounds. (17, 18)
The Pacific war, with its seaborne aerial combat, amphibious
operations and fierce Japanese Kamikaze pilots, was a
particularly bloody affair for Allied naval surgeons. LCDR
Sam R Sherman was flight surgeon on the USS Franklin when
it was severely damaged by Japanese bombing on March 19,
1945. A Japanese fighter managed to penetrate the defensive
screen around the Franklin and scored a direct hit, setting off a
chain of explosions that blew Sherman into the air, concussed
and bruised him and blew off his glasses. (19) .In a moment
a series of explosions caused hundreds of casualties. Sherman
was faced with carnage frequently described by his forebears
in the age of sail. Most of Sherman’s medical corpsmen had
been killed, blown overboard or injured. Of the other three
doctors on board the Franklin one had been killed by the
explosions. The other two, trapped by fire in the wardroom,
were not rescued for many hours. Sherman managed to
collect a group of musicians to help him and, though injured
himself and surrounded by fire and chaos, began the business
of triage and saving lives. Having spent months preparing
himself and his equipment for this moment, exercising for
disaster and making his corpsmen exercise again and again,
he put preparation into practice. While the Franklin’s damage
control crews went about the deadly serious business of saving
the ship, Sherman staunched haemorrhage, treated burns
and carried out amputations and other emergency operations.
His example deserves our attention, the more –so because of
the modesty with which he contributed his memories to oral
histories collected after WW2.
Sherman’s vivid story illustrates the resourcefulness and courage
a naval surgeon must deploy to cope with mass casualties on a
damaged ship in the middle of a modern era battle.
The story of HMAS Hobart and her response to a peace-time
crisis on Macquarie Island, in the sub-Antarctic zone
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During early January 1979, HMAS Hobart was berthed in Sydney
for maintenance. Many of her crew were on Christmas leave
and much of her machinery was at least part dismantled for
servicing. While in this state, Hobart was tasked to respond to a
civilian crisis on Macquarie Island where a biologist had fallen
down a cliff, suffering severe spinal and limb injuries. Though
the victim had been retrieved from the site of the accident to
the Macquarie Island base, a helicopter rescue was required to
move him to a ship-borne medical facility and on to the nearest
major hospital, 1450 kms in Tasmania. (20)
Hobart, a Perth Class Guided Missile Destroyer, was not
equipped to carry a helicopter: an improvised landing pad
was required. Hobart’s captain and a hastily assembled crew
brought her to partial sea readiness. They sailed her out
of Sydney on one boiler, through heavy weather with wind
exceeding 30 knots and swells over 5 meters and sailed the
2160kms to Macquarie Island. On the way they converted her
quarter deck to a temporary helicopter landing pad. At the
island they rendezvoused with the Antarctic mission support
ship, Thala Dan. The Thala Dan’s navy-trained helicopter
pilot, having retrieved the patient from the island, landed on
Hobart’s improvised quarter deck platform in heavy weather.
With the patient now under the care of her medical team,
Hobart headed to Tasmania, again at speed in heavy weather,
even though many of the crew were sea-sick under the violent
conditions. After undergoing emergency surgery in the Royal
Hobart Hospital the patient was transferred to Melbourne
but sadly, in spite of courageous efforts by all concerned, he
eventually succumbed to his injuries. This operation illustrates
what modern seaborne surgical capability can require. The
essential ingredients include personal and team enthusiasm,
commitment beyond the normal call of duty by all ranks
and disciplines, individual and organisational inventiveness,
innovation, adaptability, executive skill and a willingness
to work far away from the usual supports of land-based
medical practice. Our challenge is to utilise complex modern
resources to overcome age old problems that have always beset
seafarers: bad weather, geography, distance, isolation and all
too frequently, inadequate resources.
Concluding Remarks.
Surgeons in today’s navy must be prepared for deployments in
training, international exercises, peace time power projection
and in any of the dimensions of human conflict and disaster.
Deployments, as was the case for the Royal Navy surgeons
tasked to the convict fleets, may not always be in war or even
to sea. War service for a naval surgeon today may be on land in
Afghanistan or in a cramped ship, policing off-shore exclusion
zones in the Middle East. A modern naval surgeon may be
deployed to support the force protecting international trade
from peace-time piracy or to rescue and provide emergency
care to asylum seekers on overcrowded and often unseaworthy
fishing vessels. They may be required to work in full battle
dress in the tiny medical facility on a frigate operating in the
constant heat and humidity of a Middle Eastern war zone or in
the still cramped, hot and noisy but better equipped facilities
on amphibious landing ships. These conditions will improve
as design and technology become more sophisticated.HMAS
Manoora and Kanimbla (Landing Platform Amphibious or
LPA’s) with their Primary Casualty Receiving Facilities (PCRF,
63
now MR2E) have been valuable assets for the RAN since 1994.
The acquisition of HMS Largs Bay (now HMAS Choules) to
replace these decommissioned LPA’s will see more spacious
and better equipped medical facilities than were provided on
the LPA’s.Medical care afloat will move to even higher levels
of capacity and technological sophistication with the arrival
of the two Canberra class vessels during the next decade.
However, the factors that characterise naval surgical service
will remain. Personal and operating facilities will always be
cramped. Privacy at sea will always be limited. Ships, powering
through seas, embarking and landing helicopters or landing
craft, participating in manoeuvres or combat are noisy. The
sea will always be unpredictable. We will be expected to
innovate to deal with shortages as casualties consume available
resources or our supply lines are stretched. In peace-time
operations or in war we will be expected to show leadership as
we exercise executive skills to cope with imbalances between
demands and resources, to model new scenarios, propose new
strategies to enhance our performance, and to incorporate
the most modern technologies and techniques into our seagoing armamentarium. Our defence force medical services,
including those of the RAN, are expected to be ambassadors
for Australia and the Service, to be major permissive factors in
the increasing power projection role expected of Australia and
to be keys to the ability of Australia and her navy to respond
to threats and to humanitarian crises at home and overseas.
The qualities required are not unique to naval surgeons but are
to be found in abundance among them. As military surgeons
we take pride in the special nature and circumstances of our
work. Fortunately, the navy is not usually at war. Naval surgeons
must always have the skill and the will to look after the whole
force, in peace as well as in war and if necessary, without the
immediate support of other doctors. Life at sea produces a
wide range of injuries and morbidities, many of which may be
outside the usual patterns individual surgeon may deal with
in their civilian life. (21) Advice can usually be sought but
isolation and the other commitments a tasked ship may face
require the navy surgeon to manage wherever their skills and
knowledge are called on and to maintain the training and
commitment to do so.
The special challenge of naval surgery is to uphold the
traditions of humane service employing courageous innovation
and executive skill, at sea and on land.
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Seaman Medic Adrian Argall onboard HMAS NEWCASTLE,
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training exercise
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